Form SSA-632-BK Request to Waiver of Overpayment Recovery

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0037

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate
FOR SSA USE ONLY
ROAR Input

Yes
No

We will use your answers on this form to decide if we can waive
collection of the overpayment or change the amount you must pay us
back each month. If we can't waive collection, we may use this form
to decide how you should repay the money.

Input Date
Waiver

Approval
Denial

Please answer the questions on this form as completely as you can.
We will help you fill out the form if you want. If you are filling out
this form for someone else, answer the questions as they apply to that
person.

SSI

Yes

AMT OF OP $
PERIOD (DATES) OF OP

1.

A. Name of person on whose record
the overpayment occurred:

B. Social Security Number

C. Name of overpaid person(s) making this request and his/her Social Security Number(s):

2.

Check any of the following that apply. (Also, fill in the dollar amount in B, C, or D.)
A.

The overpayment was not my fault and I cannot afford to pay the money back and/or it is unfair for some
other reasons.

B.

I cannot afford to use all of my monthly benefit to pay back the overpayment. However I can afford
to have $
withheld each month

C.

I am no longer receiving Supplement Security Income (SSI) payments. I want to pay back $
each month instead of paying all of the money at once.

D.

I am receiving SSI payments. I want to pay back $
my total income.

Form SSA-632-BK (XX-200X) ef (XX-200X) Draft

Page 1

each month instead of paying 10% of

No

SECTION I-INFORMATION ABOUT RECEIVING THE OVERPAYMENT
3.

A. Did you, as representative payee, receive the overpaid benefits to use for the beneficiary?
Yes

No (Skip to Question 4)

B. Name and address of the beneficiary

C. How were the overpaid benefits used?

4.

If we are asking you to repay someone else's overpayment:
A. Was the overpaid person living with you when he/she was overpaid?
B. Did you receive any of the overpaid money?

Yes

No

Yes

No

C. Explain what you know about the overpayment AND why it was not your fault.

5.

Why did you think you were due the overpaid money and why do you think you were not at fault in causing the
overpayment or accepting the money?

6.

A. Did you tell us about the change or event that made you overpaid?
If no, why didn't you tell us?

Yes

No

B. If yes, how, when and where did you tell us? If you told us by phone or in person, who did you talk
with and what was said?

C. If you did not hear from us after your report, and/or your benefits did not change, did you
contact us again?

7.

A. Have we ever overpaid you before?

Yes

No

Yes

No

If yes, on what Social Security number?
B. Why were you overpaid before? If the reason is similar to why you are overpaid now, explain what you did
to try to prevent the present overpayment.

Form SSA-632-BK (XX-200X) ef (XX-200X) Draft

Page 2

FOR SSA USE ONLY
NAME:

SECTION II-YOUR FINANCIAL STATEMENT

SSN:

You need to complete this section if you are asking us either to waive the collection of the overpayment or to change the
rate at which we asked you to repay it. Please answer all questions as fully and as carefully as possible. We may ask to
see some documents to support your statements, so you should have them with you when you visit our office.
EXAMPLES ARE:

•
•
•
•

•

Current Rent or Mortgage Books
Savings Passbooks
Pay Stubs
Your most recent Tax Return

•
•

2 or 3 recent utility, medical, charge card,
and insurance bills
Cancelled checks
Similar documents for your spouse or
dependent family members

Please write only whole dollar amounts-round any cents to the nearest dollar. If you need more space for answers, use the
"Remarks" section at the bottom of page 7.

8.

9.

A. Do you now have any of the overpaid checks or money in your
possession (or in a savings or other type of account)?

Yes
Amount:$
Return this amount to SSA
No

B. Did you have any of the overpaid checks or money in your
possession (or in a savings or other type of account) at
the time you received the overpayment notice?

Yes
Amount:$
Answer Question 9.
No

Explain why you believe you should not have to return this amount.

ANSWER 10 AND 11 ONLY IF THE OVERPAYMENT IS SUPPLEMENTAL SECURITY INCOME
PAYMENTS (SSI). IF NOT, SKIP TO 12.

10.

A. Did you lend or give away any property or cash after notification
of the overpayment?

Yes (Answer Part B)
No (Go to question 11.)

B. Who received it, relationship (if any), description and value:

11.

A. Did you receive or sell any property or receive any cash (other
than earnings) after notification of this overpayment?
B. Describe property and sale price or amount of cash received:

12.

A. Are you now receiving cash public assistance such as
Supplemental Security Income (SSI) payments?

Yes (Answer Part B)
No (Go to Question 12.)

Yes

(Answer B and C and
See note below)

No

B. Name or kind of public assistance

C. Claim Number

IMPORTANT: If you answered "YES" to question 12, DO NOT answer any more questions on this form.
Go to page 8, sign and date the form, and give your address and phone number(s). Bring or mail any papers that show you
receive public assistance to your local Social Security office as soon as possible.
Form SSA-632-BK (XX-200X) ef (XX-200X) Draft

Page 3

Members Of Household

13.

List any person (child, parent, friend, etc.) who depends on you for support AND who lives with you.
NAME

AGE

RELATIONSHIP (If none, explain why the person is dependent on you)

Assets-Things You Have And Own

14.

A. How much money do you and any person(s) listed in question 13 above have
as cash on hand, in a checking account, or otherwise readily available?

$

B. Does your name, or that of any other member of your household appear,
either alone or with any other person, on any of the following?

TYPE OF ASSET

OWNER

PER MONTH

$

$

$

$

CERTIFICATES OF DEPOSIT (CD)

$

$

INDIVIDUAL RETIREMENT ACCOUNT (IRA)

$

$

MONEY OR MUTUAL FUNDS

$

$

BONDS, STOCKS

$

$

TRUST FUND

$

$

CHECKING ACCOUNT

$

$

OTHER (EXPLAIN)

$

$

$

$

SAVINGS (Bank, Savings and
Loan, Credit Union)

TOTALS

15.

BALANCE
OR VALUE

SHOW THE INCOME (interest, dividends)
EARNED EACH MONTH. (If none,
explain in spaces below. If paid
quarterly, divide by 3).

Enter the "Per Month" total on line
(k) of question 18.

A. If you or a member of your household own a car, (other than the family vehicle), van, truck,
camper, motorcycle, or any other vehicle or a boat, list below.
OWNER

YEAR, MAKE/MODEL

PRESENT
VALUE

LOAN BALANCE
(if any)

$

$

$

$

$

$

MAIN PURPOSE FOR USE

B. If you or a member of your household own any real estate (buildings or land), OTHER than where
you live, or own or have an interest in, any business, property, or valuables, describe below.
OWNER

Form SSA-632-BK(XX-200X) ef (XX-200X) Draft

DESCRIPTION

Page 4

MARKET
VALUE

LOAN BALANCE
(if any)

$

$

$

$

$

$

$

$

USAGE-INCOME
(rent etc.)

Monthly Household Income
If paid weekly, multiply by 4.33 (4 1/3) to figure monthly pay. If paid every 2 weeks, multiply by 2.166 (2 1/6). If
self-employed, enter 1/12 of net earnings. Enter monthly TAKE HOME amounts on line A of question 18 also.

16.

YES (Provide information below)

A. Are you employed?

NO (Skip to B)

Employer name, address, and phone: (Write "self" if self-employed)

B. Is your spouse employed?

Monthly TAKE-HOME
pay (NET)

$

NO (Skip to C)
Monthly pay before
deduction (Gross)
Monthly TAKE-HOME
pay (NET)

$
$

Name(s)
YES
NO (Go to Question 17)

Employer(s) name, address, and phone: (Write "self" if self-employed)

17.

$

YES (Provide information below)

Employer(s) name, address, and phone: (Write "self" if self-employed)

C. Is any other person listed
in Question 13 employed?

Monthly pay before
deduction (Gross)

A. Do you, your spouse or any dependent member of your household
receive support or contributions from any person or organization?

Monthly pay before
deduction (Gross)

$

Monthly TAKE-HOME
pay (NET)

$

YES (Answer B)

NO (Go to question 18)

SOURCE

B. How much money is received each month?
$
(Show this amount on line (J) of question 18)

BE SURE TO SHOW MONTHLY AMOUNTS BELOW - If received weekly or every 2 weeks, read the instruction at the top of this page.

18.

INCOME FROM #16 AND #17 ABOVE
AND OTHER INCOME TO YOUR HOUSEHOLD

A. TAKE HOME Pay (Net)
(From #16 A, B, C, above)

YOURS

\/

SPOUSE'S

OTHER
HOUSEHOLD
MEMBERS

\/

$

$

$

$

$

$

\/

B. Social Security Benefits
C. Supplemental Security Income (SSI)
D. Pension(s)
(VA, Military,
Civil Service,
Railroad, etc.)

TYPE

E. Public Assistance
(Other than SSI)

TYPE

TYPE

F. Food Stamps (Show full face
value of stamps received)
G. Income from real estate
(rent, etc.) (From question 15B)
H. Room and/or Board Payments
(Explain in remarks below)
I. Child Support/Alimony
J. Other Support
(From #17 (B) above)
K. Income From Assets
(From question 14)
L. Other (From any source,
explain below)
REMARKS

TOTALS

GRAND TOTAL
(Add 3 total blocks above)

Form SSA-632-BK (XX-200X) ef (XX-200X) Draft

Page 5

$

SSA USE
ONLY

MONTHLY HOUSEHOLD EXPENSES
If the expense is paid weekly or every 2 weeks, read the instruction at the top of Page 5. Do NOT list an expense that is
withheld from income (Such as Medical Insurance). Only take home pay is used to figure income.
Show "CC" as the expense amount if the expense (such as clothing)
is part of CREDIT CARD EXPENSE SHOWN ON LINE (F).

19.

$ PER MONTH

A. Rent or Mortgage (If mortgage payment includes property or other local taxes,
insurance, etc. DO NOT list again below.
B. Food (Groceries (include the value of food stamps) and food at restaurants, work, etc.)
C. Utilities (Gas, electric, telephone)
D. Other Heating/Cooking Fuel (Oil, propane, coal, wood, etc.)
E. Clothing
F. Credit Card Payments (show minimum monthly payment allowed)
G. Property Tax (State and local)
H. Other taxes or fees related to your home (trash collection, water-sewer fees)
I.

Insurance (Life, health, fire, homeowner, renter, car, and any other casualty or liability
policies)

J. Medical-Dental (After amount, if any, paid by insurance)
K. Car operation and maintenance (Show any car loan payment in (N) below)
L. Other transportation
M. Church-charity cash donations

N. Loan, credit, lay-away payments (If payment amount is optional, show minimum)

O. Support to someone NOT in household (Show name, age, relationship (if any) and
address)

P. Any expense not shown above (Specify)
EXPENSE REMARKS Also explain any unusual or very
large expenses, such as medical, college, etc.)

Form SSA-632-BK (XX-200X) ef (XX-200X) Draft

TOTAL

Page 6

$

SSA
USE
ONLY

INCOME AND EXPENSES COMPARISON
20.

A. Monthly income
(Write the amount here from the "Grand Total" of #18.

$

B. Monthly Expenses
Write the amount here from the "Total" of #19.

$
+

C. Adjusted Household Expenses
$

D. Adjusted Monthly Expenses (Add (B) and (C))

21.

$25

If your expenses (D) are more than your income (A),
explain how you are paying your bills.

FOR SSA USE ONLY
INC. EXCEEDS
ADJ EXPENSE

$

INC LESS THAN
ADJ EXPENSE

$

+

-

FINANCIAL EXPECTATION AND FUNDS AVAILABILITY
22.

A. Do you, your spouse or any dependent member of your household expect your or
their financial situation to change (for the better or worse) in the next 6 months?
(For example: a tax refund, pay raise or full repayment of a current bill for the
better-major house repairs for the worse).

B. If there is an amount of cash on hand or in checking accounts
shown in item 14A, is it being held for a special purpose?

YES (Explain on
line below)
NO

No amount on hand
NO (Money available for any use)
YES (Explain on line below)

C. Is there any reason you CANNOT convert to cash the "Balance or Value"
of any financial asset shown in item 14B.

YES (Explain on line
below)
NO

D. Is there any reason you CANNOT SELL or otherwise convert to cash
any of the assets shown in items 15A and B?

YES (Explain on line
below)
NO

REMARKS SPACE –

If you are continuing an answer to a question, please write the number (and letter,
if any) of the question first.

(MORE SPACE ON NEXT PAGE)
Form SSA-632-BK (XX-200X) ef (XX-200X) Draft

Page 7

REMARKS SPACE (Continued)

PENALTY CLAUSE, CERTIFICATION AND PRIVACY ACT STATEMENT
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.

SIGNATURE OF OVERPAID PERSON OR REPRESENTATIVE PAYEE
DATE (Month, Day, Year)

SIGNATURE (First name, middle initial, last name) (Write in ink)

HOME TELEPHONE NUMBER (Include area code)

(

)

-

WORK TELEPHONE NUMBER IF WE MAY CALL YOU AT
WORK (Include area code)

SIGN
HERE

(

)

-

MAILING ADDRESS (Number and street, Apt. No., P.O. Box, or Rural Route)

CITY AND STATE

ZIP CODE

-

ENTER NAME OF COUNTY (IF ANY) IN WHICH YOU
NOW LIVE

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the individual must sign below, giving their full addresses.
SIGNATURE OF WITNESS

SIGNATURE OF WITNESS

ADDRESS (Number and street, City, State, and ZIP Code)

ADDRESS (Number and street, City, State, and ZIP Code)

About the Privacy Act

See Revised
The Social Security Act (Sections 204, Privacy
1631(b), and
Act1870) and
the Federal Coal Mine Health and Safety Act of 1969 allow us to
collect the facts on this form. This form Statement
is voluntary. However, if
you do not give us the facts we ask for, we may not be able to
approve your waiver request. If we cannot collect the
overpayment, we may ask the Justice Department to collect it.
Sometimes the law requires us to give out the facts on this form
without your consent. We must give these facts to another person
or government agency if Federal law requires that we do so or to
do the research and audits needed to monitor and improve the
programs we manage.
We may also give these facts to the Justice Department to
investigate and prosecute violations of the Social Security Act or
we may use the facts in computer matching programs. Matching
programs compare our records with those of other Federal, State,
or local government agencies. All the Agencies may use matching
programs to find or prove that a person qualifies for benefits paid
for or managed by the Federal government. Another use is to
identify and collect overpayments or to collect overdue loans
under these benefits programs.

Form SSA-632-BK(XX-200X) ef (XX-200X) Draft

Page 8

Explanations about these and other reasons why information you
provide us may be used or given out are available in Social
Security offices. If you want to learn more about this, contact any
Social Security office.

See Revised PRA

Paperwork Reduction Act Statement - This information
collection meets the requirements of 44 U.S.C. § 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995.
You do not need to answer these questions unless we display a
valid Office of Management and Budget control number. We
estimate that it will take about 2 hours to read the instructions,
gather the facts, and answer the questions.
SEND THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies
in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). You may send comments
on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to
our time estimate to this address, not the completed form.

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement

Request for Waiver of Overpayment Recovery or Changes in Repayment Rate

Sections 204(a) and 1631(b) of the Social Security Act authorize us to collect the information
contained on this form. The information you provide is used to determine whether we can waive
collection of the overpayment or change the amount you may pay us back each month. Your
response is voluntary. However, failure to provide all or part of the requested information may
affect the processing of this form and our decision to waive collection of your overpayment or
change in your repayment rate.
We rarely use this information provided on this form for any other purpose other than the reasons
explained above. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage.
2.

To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and Department of Veterans’
Affairs); and

3. To facilitate statistical research, audit or investigative activities necessary to assure the
integrity of Social Security programs.
A complete list of routine uses for this information is available in Systems of Record Notice 600094 (Recovery of Overpayments, Accounting and Reporting/Debt Management System). This
Notice, additional information about this form, and any other information regarding our
programs, are available on-line at www.socialsecurity.gov or at your local Social Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 2 hours
to read the instructions, gather the facts, and answer the questions. Send only comments
relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 212356401.